Needle in a haystack

The challenge of finding the right person at the right time and the right place to go

This past week I was meeting my wife at our local bakery/coffee shop. I got there a few minutes early after a kid school drop off, ordered our drinks, and casually found a spot I could work at for a few minutes until she arrived. I had just flipped open my laptop when in walked a man, obviously in some type of distress, who bypassed the order line to go straight to the bathroom. Being a constant observer, I took note, but didn’t make much of it other than I thought he might be unhoused just based on his presentation.

The man came back out of the bathroom, and immediately sat down right next to me. I glanced his way and saw a hospital band on his wrist, and started to connect dots. He put his head in his hands and just sat there looking at the table. I watched as others stared, not sure what they should do, if anything, about this person. Let me pause this story and lay out some context for you, that while are about my little city, are not entirely unique to me.

I live in a town that’s about 2 hours from four major cities in three different states. It’s an interesting crossroad depending on where you are going, and is a small town of under 200,000. In the state, there are four state psychiatric hospitals, roughly divided into regions. One of these is in my town. What’s fascinating is that if you look at a map of Tennessee, you can see the huge distance between these hospitals. Meaning that depending on where you live, your crisis, and your provider’s choice, you may find yourself pretty far from home if you are hospitalized for mental health.

This piece is not about hospitals and beds, though I do think that’s an important discussion, and one I’ve had here before. This is more about the people who find themselves hospitalized, sometimes in a new town, and what happens to them after they are discharged.

Did you know? Between 1970 and 2018, there was a significant reduction of 84% in state hospital beds, with the majority of closures occurring during the 1970s and 1980s. This is largely attributed to deinstitutionalization in 1963 so it makes sense this occurred while states implemented the law.

Contrary to many assumptions about ongoing downsizing, in the most recent decade from 2010 to 2018, overall inpatient psychiatric beds across all types of organizations increased by 17 percent. Although state hospital beds decreased by 18.5 percent, private psychiatric hospital patients more than doubled, and general hospital psychiatric unit beds increased by over 25 percent.

Aside from the obvious tension between accessing specialty care and availability of beds is what happens when a person is discharged from the hospital. Sure, normally when you are discharged, you have a care plan, a support system, something that allows you to know what the next steps are. But what happens if you are placed on an involuntary hold for 72 hours? What happens if the closest hospital you are taken to is hours from your home, and there is no family or car to pick you up? Sometimes people stay in the hospital longer than they should. Sometimes they end up on the street.

Well, my friends, welcome back to my bakery and the man sitting next to me.

While I don’t know all the details, I think I know enough. This man had been hospitalized at the local psychiatric hospital. He wasn’t from here. He was released, wandered into downtown, which is close enough to the hospital, and found his way into a nice little bakery. What else is one to do when you have no place to go?

I have been in plenty of situations that call for urgent intervention. This was not one of them. The most powerful intervention I could think of was to see if this man wanted coffee and a croissant. I asked, and he didn’t reply. A few minutes later, one of the staff brought out just these things, and asked him kindly to leave. They weren’t mean or aggressive, but more understanding and sympathetic. They told him that because they were so busy, they needed all the spots in their space for paying customers. He nodded, got up with his coffee and croissant and left never saying a word.

At this point, my laptop lid being open was pointless. I was locked in on this situation watching how things went. I went up to this staff and thanked them for their kindness. They were surprised I even noticed, and in a sheepish way thanked me for my encouragement. In my experience, people in these situations tend to react out of fear rather than a position of support. I commended them for their approach, and talked to them about how often this happens. Apparently, more than they would like.

I don’t know the data around how many people are discharged from a psych hospital with no place to go or no real plan to get back home. I bet it’s a lot more than you imagine. Transportation issues are real. People not having anywhere to go after discharge is real.

There’s a lot to take away from my story that I feel has very real world implications.

First, I stand by our need for us all to better prepared to know how to talk to each other when something’s wrong. The number of people who were unable or afraid to approach this man in the bakery was too many to count. I want all of us to feel confident to approach anyone, especially those who might be in distress. It’s not a heavy lift, but one that should be essential for all of us to learn and use.

Second, we need to have seamless continuity of care that doesn’t allow people like this man to fall through the cracks. While discharge plans are required, they mean little if the person doesn’t have a car or a way home! I’ll talk about this more in a future post, but shared accountability really matters to help keep us dropping patients off and then letting them figure the rest out on their own.

Finally, we really need to reevaluate how we approach psychiatric hospitalization - specifically where they are located. While the “regionalized” approach used in my state (and other states) is a smart thing to do, we need to more evenly distribute hospitals at a local level. I think of this as an exercise that we need to do for emergency care just as much as we need to do for regular care.

As I reflect on this encounter, I am reminded of the stark realities facing individuals discharged from psychiatric hospitals, often left stranded without a realistic plan or support system. This narrative, all too common, underscores the pressing need for improved communication and compassion in our communities. It's also a call to action for seamless continuity of care forcing us to reevaluate our approach to psychiatric hospitalization amongst other things.

Care can begin with simple things like a croissant, but needs to continue to address major system reforms, too.